Bio


Dr Rahul P. Sharma, MBBS, FRACP is the Director of Structural Interventions at Stanford Healthcare, Associate Director of the Cardiac Catheterization Laboratory and Clinical Associate Professor of Medicine at Stanford University.

Dr Sharma graduated from Monash University and completed his medicine and cardiology training at the Alfred Hospital in Melbourne, Australia. He completed an advanced interventional and structural fellowship at Cedars Sinai Medical Center in Los Angeles, California in 2015 before joining Cedars Sinai as Clinical Faculty, Director of the Structural Imaging Core Laboratory and Associate Director of Interventional Cardiology Research until 2019, before joining Stanford Healthcare.

Dr Sharma is an Interventional Cardiologist with specialized clinical and research interests in structural heart disease, particularly transcatheter valve therapy. He has a large volume of expertise in transcatheter aortic, mitral and tricuspid replacement, percutaneous mitral valve repair, left atrial appendage occlusion, PFO/ASD/VSD closure, alcohol septal ablation and cerebral protection. He also has expertise in CT imaging for structural heart disease. He is a clinical investigator in ongoing national multi-center research studies and clinical trials and has co-authored numerous peer reviewed, scientific articles and book chapters. Dr Sharma also serves as a national and international clinical proctor for transcatheter aortic and mitral valve implantation and percutaneous mitral valve repair and speaks regularly at major national and international cardiology meetings.

Clinical Focus


  • Cardiovascular Disease
  • Coronary Artery Disease
  • Coronary Artery Stenosis
  • Percutaneous Coronary Intervention
  • Aortic Valve Stenosis
  • Aortic Valve Insufficiency
  • Mitral Valve Insufficiency
  • Mitral Valve Prolapse
  • Mitral Valve Stenosis
  • Tricuspid Valve
  • Tricuspid Valve Insufficiency
  • Tricuspid Valve Stenosis
  • Atrial Septal Defect
  • Ventricular Septal Defect
  • Atrial Appendage
  • Cardiomyopathy, Hypertrophic
  • TAVR
  • MitraClip
  • Transcatheter aortic valve replacement
  • TMVR
  • Transcatheter mitral valve replacement
  • Tricuspid clip
  • Transcatheter tricuspid valve replacement
  • Alcohol septal ablation
  • Watchman
  • Left atrial appendage closure
  • PFO closure
  • ASD/VSD closure
  • Paravalvular leak closure

Academic Appointments


Administrative Appointments


  • Interventional Cardiologist, Stanford Health Care (2019 - Present)
  • Clinical Assistant Professor, Stanford University (2019 - Present)
  • Director of Structural Interventions, Stanford Healthcare (2019 - Present)
  • Interventional Cardiologist, Cedars-Sinai Medical Center (2017 - 2019)
  • Research Scientist II, Department of Medicine, Cedars Sinai Medical Center (2016 - 2017)
  • Affiliate Member, Cardiac Society of Australia and New Zealand (2014 - Present)
  • Fellow, Royal Australasian College of Physicians (2012 - Present)
  • Representative, Royal Australasian College of Physicians Victorian and Tasmanian Training Committee, Australia (2011 - 2016)
  • Founder and President, Association of Victorian Cardiology Advanced Trainees, Australia (2011 - 2014)

Honors & Awards


  • Excellence in Teaching Award 2017-2018, Cedars Sinai Medical Center (2018)
  • Recipient of Academic Scholarship for Masters in Health Delivery Sciences, - (2018)
  • Winner – “Medtech’s Got Talent” Innovation Award, - (2014)
  • Finalist – Royal Australian College of Physicians Research Prize, - (2012)
  • Winner – Alfred Health Senior Medical Staff Research Scholarship, - (2012)
  • Winner – Alfred Health Teacher of the Year Award, - (2012)
  • Winner – Anglican Church Grammar School Old Boy’s Association Scholarship, - (2012)
  • Finalist – Alfred Health Research Prize, - (2011)
  • No. 1 ranked candidate overall for entrance to Cardiology Fellowship, - (2011)
  • Winner – Alfred Health Teacher of the Year Award, - (2011)
  • Winner – Monash University Medical Students Teaching Award, - (2011)
  • Winner – Victoria Cardiology Registrar’s Research Prize, Cardiac Society of Australia and New Zealand (2011)
  • Winner – Alfred Health Teaching Supervisors Award, - (2010)
  • Winner – Novartis research travel scholarship, - (2009)
  • Winner – Baker IDI research travel scholarship, - (2007)
  • Finalist – Australian and New Zealand Society for Geriatric Medicine Prize, - (2006)
  • Finalist – Prince Henry’s Institute Surgical Prize, - (2006)
  • Winner – Monash University overseas elective scholarship, - (2006)

Boards, Advisory Committees, Professional Organizations


  • Fellow, Cardiac Society of Australia and New Zealand (2014 - Present)
  • Fellow, Royal Australian College of Physicians (2014 - Present)

Professional Education


  • Board Certification: Royal Australasian College of Physicians - Australia, Cardiology (2013)
  • Fellowship, Cedars Sinai Medical Center, Interventional and Structural Cardiology, Los Angeles, CA (2015)
  • Fellowship, Alfred Hospital, Cardiology Advanced Physician Training, Melbourne, Australia (2014)
  • Fellowship, Monash Medical Center, Melbourne, Australia (2014)
  • Fellowship, Royal Australasian College of Surgeons, Alfred Health, Melbourne, Australia (2013)
  • Residency, Alfred Hospital, General Medicine, Melbourne, Australia (2011)
  • Internship, Alfred Hospital, Melbourne, Australia (2011)
  • MBBS, Monash University, Bachelor of Medicine, Bachelor of Surgery, Melbourne, Australia (2006)

Current Research and Scholarly Interests


Transcatheter valve therapies, CT valve imaging, AI and device innovation

Clinical Trials


  • 2019-06 TRISCEND Study Recruiting

    Early feasibility study to assess safety and performance of the Edwards EVOQUE Tricuspid Valve Replacement System

    View full details

  • ACURATE IDE: Safety and Effectiveness Study of ACURATE Valve for Transcatheter Aortic Valve Replacement Recruiting

    To evaluate safety and effectiveness of the ACURATE Transfemoral Aortic Valve System for transcatheter aortic valve replacement (TAVR) in subjects with severe native aortic stenosis who are indicated for TAVR.

    View full details

  • Clinical Trial to Evaluate the Safety and Effectiveness of Using the Tendyne Mitral Valve System for the Treatment of Symptomatic Mitral Regurgitation Recruiting

    Prospective, controlled, multicenter clinical investigation with three trial cohorts: Randomized, Non-Randomized, and Mitral Annular Calcification (MAC). Subjects in the Randomized cohort will be randomized in a 1:1 ratio to the trial device or to the MitraClip system. Subjects in the Non-Randomized and MAC cohorts will receive the trial device. The objective of the Clinical Trial to Evaluate the Safety and Effectiveness of Using the Tendyne Mitral Valve System for the Treatment of Symptomatic Mitral Regurgitation (SUMMIT) is to evaluate the safety and effectiveness of the Tendyne Mitral Valve System for the treatment of patients with symptomatic, moderate-to-severe or severe mitral regurgitation or for patients with symptomatic mitral valve disease due to severe mitral annular calcification. This randomized controlled trial will provide the opportunity to evaluate the safety and clinical benefits of the Tendyne Mitral Valve System compared to the MitraClip System in patients with symptomatic, moderate-to-severe or severe mitral regurgitation, within approved MitraClip indications. In addition, the safety and effectiveness of the Tendyne Mitral Valve System will be evaluated in patients with severe mitral annular calcification who are at prohibitive risk for mitral valve surgery. Patients who are not suitable for mitral valve surgery for reasons other than severe mitral annular calcification and are also not suitable for transcatheter repair with MitraClip, will be enrolled in the Non-randomized cohort. Subjects will be seen at screening, pre- and post-procedure, discharge, 30 days, 3 months, 6 months, and annually through 5 years.

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  • Edwards PASCAL CLASP IID/IIF Pivotal Clinical Trial Recruiting

    To establish the safety and effectiveness of the Edwards PASCAL Transcatheter Valve Repair System in patients with degenerative mitral regurgitation (DMR) who have been determined to be at prohibitive risk for mitral valve surgery by the Heart Team, and in patients with functional mitral regurgitation (FMR) on guideline directed medical therapy (GDMT)

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  • MitraClip REPAIR MR Study Recruiting

    The objective of this randomized controlled trial (RCT) is to compare the clinical outcome of MitraClip™ device versus surgical repair in patients with severe primary MR who are at moderate surgical risk and whose mitral valve has been determined to be suitable for correction by MV repair surgery by the cardiac surgeon on the local site heart team.

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  • PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis Recruiting

    To establish the safety and effectiveness of the Edwards SAPIEN 3 Transcatheter Heart Valve (THV) in patients with severe, calcific aortic stenosis who are at low operative risk for standard aortic valve replacement.

    View full details

  • Transcatheter Mitral Valve Replacement With the Medtronic Intrepid™ TMVR System in Patients With Severe Symptomatic Mitral Regurgitation Recruiting

    Multi-center, global, prospective, non-randomized, interventional, pre-market trial. All subjects enrolled with receive the study device.

    View full details

  • Edwards PASCAL Transcatheter Valve Repair System Pivotal Clinical Trial Not Recruiting

    To establish the safety and effectiveness of the Edwards PASCAL Transcatheter Repair System in patients with symptomatic severe tricuspid regurgitation who have been determined to be at an intermediate or greater estimated risk of mortality with tricuspid valve surgery by the cardiac surgeon with concurrence by the local Heart Team

    Stanford is currently not accepting patients for this trial.

    View full details

  • TRISCEND II Pivotal Trial Not Recruiting

    Pivotal trial to evaluate the safety and effectiveness of the Edwards EVOQUE tricuspid valve replacement system

    Stanford is currently not accepting patients for this trial.

    View full details

All Publications


  • A randomized evaluation of the TriGuard HDH cerebral embolic protection device to Reduce the Impact of Cerebral Embolic LEsions after TransCatheter Aortic Valve ImplanTation: the REFLECT I trial. European heart journal Lansky, A. J., Makkar, R., Nazif, T., Messe, S., Forrest, J., Sharma, R., Schofer, J., Linke, A., Brown, D., Dhoble, A., Horwitz, P., Zang, M., DeMarco, F., Rajagopal, V., Dwyer, M. G., Zivadinov, R., Stella, P., Rovin, J., Parise, H., Kodali, S., Baumbach, A., Moses, J., REFLECT I Trial Investigators 2021

    Abstract

    AIMS: The REFLECT I trial investigated the safety and effectiveness of the TriGuard HDH (TG) cerebral embolic deflection device in patients undergoing transcatheter aortic valve replacement (TAVR).METHODS AND RESULTS: This prospective, multicentre, single-blind, 2:1 randomized (TG vs. no TG) study aimed to enrol up to 375 patients, including up to 90 roll-in patients. The primary combined safety endpoint (VARC-2 defined early safety) at 30days was compared with a performance goal. The primary efficacy endpoint was a hierarchical composite of (i) all-cause mortality or any stroke at 30days, (ii) National Institutes of Health Stroke Scale (NIHSS) worsening at 2-5days or Montreal Cognitive Assessment worsening at 30days, and (iii) total volume of cerebral ischaemic lesions detected by diffusion-weighted magnetic resonance imaging at 2-5days. Cumulative scores were compared between treatment groups using the Finkelstein-Schoenfeld method. A total of 258 of the planned, 375 patients (68.8%) were enrolled (54 roll-in and 204 randomized). The primary safety outcome was met compared with the performance goal (21.8% vs. 35%, P<0.0001). The primary hierarchical efficacy endpoint was not met (mean efficacy score, higher is better: -5.3±99.8 TG vs. 11.8±96.4 control, P=0.31). Covert central nervous system injury was numerically lower with TG both in-hospital (46.1% vs. 60.3%, P=0.0698) and at 5days (61.7 vs. 76.2%, P=0.054) compared with controls.CONCLUSION: REFLECT I demonstrated that TG cerebral protection during TAVR was safe in comparison with historical TAVR data but did not meet the predefined effectiveness endpoint compared with unprotected TAVR controls.

    View details for DOI 10.1093/eurheartj/ehab213

    View details for PubMedID 34000004

  • Randomized Evaluation of TriGuard 3 Cerebral Embolic Protection After Transcatheter Aortic Valve Replacement: REFLECT II. JACC. Cardiovascular interventions Nazif, T. M., Moses, J. n., Sharma, R. n., Dhoble, A. n., Rovin, J. n., Brown, D. n., Horwitz, P. n., Makkar, R. n., Stoler, R. n., Forrest, J. n., Messé, S. n., Dickerman, S. n., Brennan, J. n., Zivadinov, R. n., Dwyer, M. G., Lansky, A. J. 2021; 14 (5): 515–27

    Abstract

    The REFLECT II (Randomized Evaluation of TriGuard 3 Cerebral Embolic Protection After Transcatheter Aortic Valve Implantation) trial was designed to investigate the safety and efficacy of the TriGUARD 3 (TG3) cerebral embolic protection in patients undergoing transcatheter aortic valve replacement.Cerebral embolization occurs frequently following transcatheter aortic valve replacement and procedure-related ischemic stroke occurs in 2% to 6% of patients at 30 days. Whether cerebral protection with TriGuard 3 is safe and effective in reducing procedure-related cerebral injury is not known.This prospective, multicenter, single-blind, 2:1 randomized (TG3 vs. no TG3) study was designed to enroll up to 345 patients. The primary 30-day safety endpoint (Valve Academic Research Consortium-2 defined) was compared with a performance goal (PG). The primary hierarchical composite efficacy endpoint (including death or stroke at 30 days, National Institutes of Health Stroke Scale score worsening in hospital, and cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging at 2 to 5 days) was compared using the Finkelstein-Schoenfeld method.REFLECT II enrolled 220 of the planned 345 patients (63.8%), including 41 roll-in and 179 randomized patients (121 TG3 and 58 control subjects) at 18 US sites. The sponsor closed the study early after the U.S. Food and Drug Administration recommended enrollment suspension for unblinded safety data review. The trial met its primary safety endpoint compared with the PG (15.9% vs. 34.4% (p < 0.0001). The primary hierarchal efficacy endpoint at 30 days was not met (mean scores [higher is better]: -8.58 TG3 vs. 8.08 control; p = 0.857). A post hoc diffusion-weighted magnetic resonance imaging analysis of per-patient total lesion volume above incremental thresholds showed numeric reductions in total lesion volume >500 mm3 (-9.7%) and >1,000 mm3 (-44.5%) in the TG3 group, which were more pronounced among patients with full TG3 coverage: -51.1% (>500 mm3) and -82.9% (>1,000 mm3).The REFLECT II trial demonstrated that the TG3 was safe compared with a historical PG but did not meet its pre-specified primary superiority efficacy endpoint.

    View details for DOI 10.1016/j.jcin.2020.11.011

    View details for PubMedID 33663779

  • Transcatheter aortic valve thrombosis: a review of potential mechanisms. Journal of the Royal Society, Interface Raghav, V., Midha, P., Sharma, R., Babaliaros, V., Yoganathan, A. 2021; 18 (184): 20210599

    Abstract

    Transcatheter aortic valve (TAV) thrombosis has been recognized as a significant problem that sometimes occurs as early as within 30 days after valve implantation, leading to increased concerns of stroke and long-term valve durability. In this article, a critical summary of the relevant literature on identifying potential mechanisms of TAV thrombosis from the perspective of the well-known Virchow's triad, which comprises blood flow, foreign materials and blood biochemistry, is presented. Blood flow mechanisms have been the primary focus thus far, with a general consensus on the flow mechanisms with respect to haemodynamic conditions, the influence of TAV placement and expansion and the influence of coronary flow. Less attention has been paid to the influence of blood biochemistry and foreign materials (and related endothelial damage), with little consensus among studies with regards to platelet and/or microparticle levels post-TAV implantation. Finally, we discuss the future outlook for research with unanswered scientific questions.

    View details for DOI 10.1098/rsif.2021.0599

    View details for PubMedID 34814733

  • Randomized Trials Are Needed for Transcatheter Mitral Valve Replacement. JACC. Cardiovascular interventions Rogers, J. H., Sorajja, P., Thourani, V. H., Sharma, R. P., Chehab, B., Cowger, J., Heimansohn, D., Badhwar, V., Guerrero, M., Ailawadi, G. 2021; 14 (18): 2039-2046

    Abstract

    Transcatheter mitral valve replacement (TMVR) is a new therapy for treating symptomatic mitral regurgitation (MR) and stenosis. The proposed benefit of TMVR is the predictable, complete elimination of MR, which is less certain with transcatheter repair technologies such as TEER (transcatheter edge-to-edge repair). The potential benefit of MR elimination with TMVR needs to be rigorously evaluated against its risks which include relative procedural invasiveness, need for anticoagulation, and chronic structural valve deterioration. Randomized controlled trials (RCTs) are a powerful method for evaluating the safety and effectiveness of TMVR against current standard of care transcatheter therapies, such as TEER. RCTs not only help with the assessment of benefits and risks, but also with policies for determining operator or institutional requirements, resource utilization, and reimbursement. In this paper, the authors provide recommendations and considerations for designing pivotal RCTs for first-in-class TMVR devices.

    View details for DOI 10.1016/j.jcin.2021.06.014

    View details for PubMedID 34556279

  • The role of flow stasis in transcatheter aortic valve leaflet thrombosis. The Journal of thoracic and cardiovascular surgery Trusty, P. M., Bhat, S. S., Sadri, V., Salim, M. T., Funnell, E., Kamioka, N., Sharma, R., Makkar, R., Babaliaros, V., Yoganathan, A. P. 2020

    Abstract

    OBJECTIVE: With the recent expanded indication for transcatheter aortic valve replacement to low-risk surgical patients, thrombus formation in the neosinus is of particular interest due to concerns of reduced leaflet motion and long-term transcatheter heart valve durability. Although flow stasis likely plays a role, a direct connection between neosinus flow stasis and thrombus severity is yet to be established.METHODS: Patients (n=23) were selected to minimize potential confounding factors related to thrombus formation. Patient-specific 3-dimensional reconstructed invitro models were created to replicate invivo anatomy and valve deployment using the patient-specific cardiac output and idealized coronary flows. Dye was injected into each neosinus to quantify washout time as a measure of flow stasis.RESULTS: Flow stasis (washout time) showed a significant, positive correlation with thrombus volume in the neosinus (rho=0.621, P<.0001). Neither thrombus volume nor washout time was significantly different in the left, right, and noncoronary neosinuses (P≥.54).CONCLUSIONS: This is the first patient-specific study correlating flow stasis with thrombus volume in the neosinus post-transcatheter aortic valve replacement across multiple valve types and sizes. Neosinus-specific factors create hemodynamic and thrombotic variability within individual patients. Measurement of neosinus flow stasis may guide strategies to improve outcomes in transcatheter aortic valve replacement.

    View details for DOI 10.1016/j.jtcvs.2020.10.139

    View details for PubMedID 33342573

  • A Review of the Partner Trials. Interventional cardiology clinics Markham, R., Sharma, R. 2020; 9 (4): 461–67

    Abstract

    Aortic stenosis (AS) of moderate or greater severity has an estimated prevalence of 5% in people older than 65 years. Survival is poor after onset of symptoms, and surgical aortic valve replacement was the gold-standard treatment for decades. However, more than one-third of patients with symptomatic AS were untreated due to high surgical risk, exposing a clinical need for a less invasive therapy for aortic valve stenosis. The PARTNER trials were pivotal in presenting robust evidence for the safety, feasibility, and efficacy of transcatheter aortic valve replacement in the management of AS and paved the way for clinical use worldwide.

    View details for DOI 10.1016/j.iccl.2020.07.002

    View details for PubMedID 32921370

  • Self-expanding intra-annular versus commercially available transcatheter heart valves in high and extreme risk patients with severe aortic stenosis (PORTICO IDE): a randomised, controlled, non-inferiority trial. Lancet (London, England) Makkar, R. R., Cheng, W., Waksman, R., Satler, L. F., Chakravarty, T., Groh, M., Abernethy, W., Russo, M. J., Heimansohn, D., Hermiller, J., Worthley, S., Chehab, B., Cunningham, M., Matthews, R., Ramana, R. K., Yong, G., Ruiz, C. E., Chen, C., Asch, F. M., Nakamura, M., Jilaihawi, H., Sharma, R., Yoon, S., Pichard, A. D., Kapadia, S., Reardon, M. J., Bhatt, D. L., Fontana, G. P. 2020

    Abstract

    BACKGROUND: Randomised trial data assessing the safety and efficacy of the self-expanding intra-annular Portico transcatheter aortic valve system (Abbott Structural Heart, St Paul, MN, USA) compared with any commercially available valves are needed to compare performance among designs.METHODS: In this prospective, multicentre, non-inferiority, randomised controlled trial (the Portico Re-sheathable Transcatheter Aortic Valve System US Investigational Device Exemption trial [PORTICO IDE]), high and extreme risk patients with severe symptomatic aortic stenosis were recruited from 52 medical centres experienced in performing transcatheter aortic valve replacement in the USA and Australia. Patients were eligible if they were aged 21 years or older, in New York Heart Association functional class II or higher, and had severe native aortic stenosis. Eligible patients were randomly assigned (1:1) using permuted block randomisation (block sizes of 2 and 4) and stratified by clinical investigational site, surgical risk cohort, and vascular access method, to transcatheter aortic valve replacement with the first generation Portico valve and delivery system or a commercially available valve (either an intra-annular balloon-expandable Edwards-SAPIEN, SAPIEN XT, or SAPIEN 3 valve [Edwards LifeSciences, Irvine, CA, USA]; or a supra-annular self-expanding CoreValve, Evolut-R, or Evolut-PRO valve [Medtronic, Minneapolis, MN, USA]). Investigational site staff, implanting physician, and study participant were unmasked to treatment assignment. Core laboratories and clinical event assessors were masked to treatment allocation. The primary safety endpoint was a composite of all-cause mortality, disabling stroke, life-threatening bleeding requiring transfusion, acute kidney injury requiring dialysis, or major vascular complication at 30 days. The primary efficacy endpoint was all-cause mortality or disabling stroke at 1 year. Clinical outcomes and valve performance were assessed up to 2 years after the procedure. Primary analyses were by intention to treat and the Kaplan-Meier method to estimate event rates. The non-inferiority margin was 8·5% for primary safety and 8·0% for primary efficacy endpoints. This study is registered with ClinicalTrials.gov, NCT02000115, and is ongoing.FINDINGS: Between May 30 and Sept 12, 2014, and between Aug 21, 2015, and Oct 10, 2017, with recruitment paused for 11 months by the funder, we recruited 1034 patients, of whom 750 were eligible and randomly assigned to the Portico valve group (n=381) or commercially available valve group (n=369). Mean age was 83 years (SD 7) and 395 (52·7%) patients were female. For the primary safety endpoint at 30 days, the event rate was higher in the Portico valve group than in the commercial valve group (52 [13·8%] vs 35 [9·6%]; absolute difference 4·2, 95% CI -0·4 to 8·8 [upper confidence bound {UCB} 8·1%]; pnon-inferiority=0·034, psuperiority=0·071). At 1 year, the rates of the primary efficacy endpoint were similar between the groups (55 [14·8%] in the Portico group vs 48 [13·4%] in the commercial valve group; difference 1·5%, 95% CI -3·6 to 6·5 [UCB 5·7%]; pnon-inferiority=0·0058, psuperiority=0·50). At 2 years, rates of death (80 [22·3%] vs 70 [20·2%]; p=0·40) or disabling stroke (10 [3·1%] vs 16 [5·0%]; p=0·23) were similar between groups.INTERPRETATION: The Portico valve was associated with similar rates of death or disabling stroke at 2 years compared with commercial valves, but was associated with higher rates of the primary composite safety endpoint including death at 30 days. The first-generation Portico valve and delivery system did not offer advantages over other commercially available valves.FUNDING: Abbott.

    View details for DOI 10.1016/S0140-6736(20)31358-1

    View details for PubMedID 32593323

  • Comparison of Valve Performance of the Intra-Annular Self-Expanding Portico (TM) Transcatheter Aortic Valve With Contemporary Supra-Annular Self-Expanding and Intra-Annular Balloon-Expandable Valves: Insights From the PORTICO IDE Trial Makkar, R. R., Waksman, R., Groh, M., Russo, M. J., Hermiller, J., Worthley, S., Chehab, B., Asch, F. M., Sharma, R. P., Jilaihawi, H., Pichard, A. D., Reardon, M. J., Fontana, G. P. ELSEVIER SCIENCE INC. 2020: S46
  • Percutaneous Pulmonary Vein Stenting to Treat Severe Pulmonary Vein Stenosis After Surgical Reconstruction. Innovations (Philadelphia, Pa.) Dalal, A. R., Markham, R. n., Haeffele, C. n., Sharma, R. n., Watkins, A. C. 2020: 1556984520933962

    Abstract

    A 36-year-old female underwent left lower lobectomy with left atrial and left upper pulmonary vein (LUPV) reconstruction with a bovine pericardial patch for an intrathoracic pheochromocytoma. Postoperatively, she developed shortness of breath and transesophageal echocardiography demonstrated LUPV stenosis with increased velocities. Computed tomography angiogram of the chest revealed LUPV stenosis at the left atrium ostium with an area of 39 mm2. Under angiographic and echocardiographic guidance, a 10 × 19 mm Omnilink Elite uncovered stent was deployed in the LUPV ostia. While reported following left atrial ablation, pulmonary vein stenting can be successful in a pulmonary vein surgically reconstructed with bovine pericardium.

    View details for DOI 10.1177/1556984520933962

    View details for PubMedID 32639846

  • Endovascular Neuromodulation: Safety Profile and Future Directions. Frontiers in neurology Raza, S. A., Opie, N. L., Morokoff, A., Sharma, R. P., Mitchell, P. J., Oxley, T. J. 2020; 11: 351

    Abstract

    Endovascular neuromodulation is an emerging technology that represents a synthesis between interventional neurology and neural engineering. The prototypical endovascular neural interface is the StentrodeTM, a stent-electrode array which can be implanted into the superior sagittal sinus via percutaneous catheter venography, and transmits signals through a transvenous lead to a receiver located subcutaneously in the chest. Whilst the StentrodeTM has been conceptually validated in ovine models, questions remain about the long term viability and safety of this device in human recipients. Although technical precedence for venous sinus stenting already exists in the setting of idiopathic intracranial hypertension, long term implantation of a lead within the intracranial veins has never been previously achieved. Contrastingly, transvenous leads have been successfully employed for decades in the setting of implantable cardiac pacemakers and defibrillators. In the current absence of human data on the StentrodeTM, the literature on these structurally comparable devices provides valuable lessons that can be translated to the setting of endovascular neuromodulation. This review will explore this literature in order to understand the potential risks of the StentrodeTM and define avenues where further research and development are necessary in order to optimize this device for human application.

    View details for DOI 10.3389/fneur.2020.00351

    View details for PubMedID 32390937

  • Timing and Outcomes of Percutaneous Coronary Intervention in Patients Who Underwent Transcatheter Aortic Valve Implantation. The American journal of cardiology Ochiai, T. n., Yoon, S. H., Flint, N. n., Sharma, R. n., Chakravarty, T. n., Kaewkes, D. n., Patel, V. n., Nakamura, M. n., Cheng, W. n., Makkar, R. n. 2020

    Abstract

    Limited data exist regarding the timing of percutaneous coronary intervention (PCI) in patients with coronary artery disease who underwent transcatheter aortic valve implantation (TAVI). We aimed to investigate clinical outcomes of patients who underwent TAVI and planned PCI according to the timing of PCI in relation to the TAVI. Consecutive patients with severe aortic stenosis who underwent TAVI with planned PCI between January 2013 and November 2017 were included. Patients were divided according to the timing of PCI. The primary end point was major adverse cardiac and cerebrovascular events, defined as a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke. Among 1,756 patients who underwent TAVI, 258 patients underwent planned PCI either before TAVI (n = 143, 55.4%), concomitantly with TAVI (n = 77, 29.8%), or after TAVI (n = 38, 14.7%). All patients in the post-TAVI PCI group were treated using balloon-expandable valves, and neither hemodynamic instability during TAVI nor PCI-related complications were observed. In a multivariable analysis, the timing of PCI was not associated with 2-year major adverse cardiac and cerebrovascular events rate (concomitant vs pre-TAVI, hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.52 to 1.66; p = 0.79; post- vs pre-TAVI, HR: 0.45; 95% CI: 0.18 to 1.16; p = 0.10). In conclusion, there were no significant differences in terms of mid-term outcomes among pre-TAVI, concomitant, and post-TAVI PCI groups when the timing of PCI was carefully selected by heart team.

    View details for DOI 10.1016/j.amjcard.2020.01.043

    View details for PubMedID 32106928

  • Motor neuroprosthesis implanted with neurointerventional surgery improves capacity for activities of daily living tasks in severe paralysis: first in-human experience. Journal of neurointerventional surgery Oxley, T. J., Yoo, P. E., Rind, G. S., Ronayne, S. M., Lee, C. M., Bird, C. n., Hampshire, V. n., Sharma, R. P., Morokoff, A. n., Williams, D. L., MacIsaac, C. n., Howard, M. E., Irving, L. n., Vrljic, I. n., Williams, C. n., John, S. E., Weissenborn, F. n., Dazenko, M. n., Balabanski, A. H., Friedenberg, D. n., Burkitt, A. N., Wong, Y. T., Drummond, K. J., Desmond, P. n., Weber, D. n., Denison, T. n., Hochberg, L. R., Mathers, S. n., O'Brien, T. J., May, C. N., Mocco, J. n., Grayden, D. B., Campbell, B. C., Mitchell, P. n., Opie, N. L. 2020

    Abstract

    Implantable brain-computer interfaces (BCIs), functioning as motor neuroprostheses, have the potential to restore voluntary motor impulses to control digital devices and improve functional independence in patients with severe paralysis due to brain, spinal cord, peripheral nerve or muscle dysfunction. However, reports to date have had limited clinical translation.Two participants with amyotrophic lateral sclerosis (ALS) underwent implant in a single-arm, open-label, prospective, early feasibility study. Using a minimally invasive neurointervention procedure, a novel endovascular Stentrode BCI was implanted in the superior sagittal sinus adjacent to primary motor cortex. The participants undertook machine-learning-assisted training to use wirelessly transmitted electrocorticography signal associated with attempted movements to control multiple mouse-click actions, including zoom and left-click. Used in combination with an eye-tracker for cursor navigation, participants achieved Windows 10 operating system control to conduct instrumental activities of daily living (IADL) tasks.Unsupervised home use commenced from day 86 onwards for participant 1, and day 71 for participant 2. Participant 1 achieved a typing task average click selection accuracy of 92.63% (100.00%, 87.50%-100.00%) (trial mean (median, Q1-Q3)) at a rate of 13.81 (13.44, 10.96-16.09) correct characters per minute (CCPM) with predictive text disabled. Participant 2 achieved an average click selection accuracy of 93.18% (100.00%, 88.19%-100.00%) at 20.10 (17.73, 12.27-26.50) CCPM. Completion of IADL tasks including text messaging, online shopping and managing finances independently was demonstrated in both participants.We describe the first-in-human experience of a minimally invasive, fully implanted, wireless, ambulatory motor neuroprosthesis using an endovascular stent-electrode array to transmit electrocorticography signals from the motor cortex for multiple command control of digital devices in two participants with flaccid upper limb paralysis.

    View details for DOI 10.1136/neurintsurg-2020-016862

    View details for PubMedID 33115813

  • Variation in the Timing of Percutaneous Coronary Intervention and Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement Ochiai, T., Yoon, S., Flint, N., Sharma, R., Patel, V., Chakravarty, T., Nakamura, M., Cheng, W., Makkar, R. ELSEVIER SCIENCE INC. 2019: B670
  • Patching residual leaks following a MitraClip procedure EUROINTERVENTION Kar, S., Sharma, R. 2019; 15 (6): E482–E483

    View details for DOI 10.4244/EIJV15I6A87

    View details for Web of Science ID 000490324300003

    View details for PubMedID 31395574

  • Computed tomography characteristics of the aortic valve and the geometry of SAPIEN 3 transcatheter heart valve in patients with bicuspid aortic valve disease EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Kawamori, H., Yoon, S., Chakravarty, T., Maeno, Y., Kashif, M., Israr, S., Abramowitz, Y., Mangat, G., Miyasaka, M., Rami, T., Kazuno, Y., Takahashi, N., Jilaihawi, H., Nakamura, M., Cheng, W., Friedman, J., Berman, D., Sharma, R., Makkar, R. R. 2018; 19 (12): 1408–18

    Abstract

    We assessed the geometry of transcatheter heart valve (THV) and valve function associated with SAPIEN 3 implantation in patients with bicuspid aortic valve (BAV) stenosis.We included 280 consecutive patients who had a contrast computed tomography (CT) before and after transcatheter aortic valve implantation (TAVI) in our institution. Each THV was assessed by CT at five cross-sectional levels: inflow, annulus, mid, sinus, and outflow. The geometry of THV was assessed for eccentricity (1 - minimum diameter/maximum diameter) and expansion (CT derived external valve area/nominal external valve area). CT measurements and transthoracic echocardiogram data were compared between BAV and tricuspid aortic valve (TAV). Among 280 patients, 41 patients were diagnosed as BAV. Compared to TAV, BAV was associated with lower expansion at mid-level, sinus-level, and outflow-level (mid 94.1 ± 6.8% vs. 98.1 ± 7.8%; P = 0.002, sinus 95.9 ± 7.2% vs. 101.6 ± 8.5%; P < 0.001, outflow 107.6 ± 6.2% vs. 109.9 ± 6.6%; P = 0.043), and higher eccentricity at all levels [inflow 3.5% (1.9-5.3) vs. 6.0% (3.2-7.5); P < 0.001, annulus 3.1% (1.6-5.2) vs. 5.4% (3.1-7.8); P = 0.002, mid 3.0% (1.4-4.9) vs. 6.0% (3.3-10.4); P < 0.001, sinus 3.0% (1.7-5.1) vs. 7.6% (4.0-11.4); P < 0.001, and outflow 2.5% (1.3-4.3) vs. 4.9% (2.2-7.5); P < 0.001]. There were no differences in frequency of paravalvular leak ≥ moderate and mean post-procedural gradient between BAV and TAV.BAV patients have greater THV eccentricity at all levels and lower THV expansion at mid, sinus, and outflow levels than the TAV patients. There were no differences in parameters of valve function between BAV and TAV patients. Despite the observed geometrical differences, TAVI with SAPIEN 3 in BAV patients allows for feasible valve function.

    View details for DOI 10.1093/ehjci/jex333

    View details for Web of Science ID 000455360200016

    View details for PubMedID 29315371

  • Transcatheter aortic valve replacement in bicuspid aortic valve stenosis: where do we stand? JOURNAL OF CARDIOVASCULAR SURGERY Yoon, S., Sharma, R., Chakravarty, T., Miyasaka, M., Ochiai, T., Nomura, T., Gellada, N., Nemanpour, S., Nakamura, M., Chen, W., Makkar, R. 2018; 59 (3): 381–91

    Abstract

    Bicuspid aortic valve is the most common congenital cardiac defect in adults, and symptom typically develops in adulthood. In the majority of cases, bicuspid aortic valve disease progress with ages and surgical aortic valve replacement is performed with excellent operative outcomes. However, with the relatively slow progression of disease, surgical aortic valve replacement is required in elderly patients but the surgical risk often deemed extremely high due to old age and multiple comorbidities. Transcatheter aortic valve replacement (TAVR) has evolved from a novel technology to an established therapy for intermediate- and high-risk patients with symptomatic severe aortic valve stenosis (AS). Numerous studies have demonstrated the safety and efficacy of TAVR, and more than 250,000 patients have been treated with this technology. Although randomized trials have established TAVR as the standard treatment, these trials excluded congenital bicuspid AS due to its unique morphological features. Nevertheless, the growing experience, accumulated knowledge, and advancements of new technology lead to the expand use of TAVR to other pathologies or other populations such as bicuspid AS. With integration of imaging multimodalities (computed tomography and echocardiography), the diagnosis and classification of bicuspid aortic valve has been changing. Due to unfavorable anatomic features of bicuspid AS, the outcomes of TAVR in bicuspid AS was suboptimal, particularly when using the first-generation transcatheter valves. However, the newer-generation transcatheter valves significantly improved the outcomes of TAVR in bicuspid AS. Nonetheless, several issues still remain to be resolved. Given longer life expectancy in patients with bicuspid AS undergoing TAVR, durability of transcatheter valves is concerned. In addition, patients with bicuspid aortic valves often have concomitant dilatation of proximal part of ascending aorta (aortopathy), but limited data exist about the clinical prognosis of bicuspid aortic valve with concomitant aortopathy in elderly patients. Considering the expanding indication of TAVR to lower surgical risk and younger population, these issues should be evaluated in future studies.

    View details for DOI 10.23736/S0021-9509.18.10350-8

    View details for Web of Science ID 000445207000014

    View details for PubMedID 29332374

  • Response by Sharma et al to Letter Regarding Article, "The Fluid Mechanics of Transcatheter Heart Valve Leaflet Thrombosis in the Neosinus". Circulation Sharma, R., Midha, P. A., Babaliaros, V., Makkar, R. R., Yoganathan, A. P. 2018; 137 (19): 2094-2095

    View details for DOI 10.1161/CIRCULATIONAHA.118.033769

    View details for PubMedID 29735601

  • Recurrent severe aortic stenosis after transfemoral transcatheter valve-in-valve-in-valve replacement JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Ochiai, T., Yoon, S., Sharma, R., Chakravarty, T., Nakamura, M., Cheng, W., Makkar, R. 2018; 155 (5): E141–E144

    View details for DOI 10.1016/j.jtcvs.2017.12.120

    View details for Web of Science ID 000430195900001

    View details for PubMedID 29422220

  • Too little, too much or just right? Goldilocks revisited…. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Sharma, R., Henry, T. D. 2018; 91 (5): 840-841

    Abstract

    This study highlights the low rates of UCA in OHCA patients in a real-world setting Presentation with ST elevation, shockable rhythm and history of CAD were more likely to result in UCA for OHCA patients Further studies are required to help create a systematic and standardized approach to UCA in OHCA patients.

    View details for DOI 10.1002/ccd.27613

    View details for PubMedID 29634858

  • Relation Between Left Ventricular Outflow Tract Calcium and Mortality Following Transcatheter Aortic Valve Implantation AMERICAN JOURNAL OF CARDIOLOGY Maeno, Y., Abramowitz, Y., Yoon, S., Israr, S., Jilaihawi, H., Watanabe, Y., Sharma, R., Kawamori, H., Miyasaka, M., Kazuno, Y., Takahashi, N., Hariri, B., Mangat, G., Kashif, M., Chakravarty, T., Nakamura, M., Cheng, W., Makkar, R. R. 2017; 120 (11): 2017–24

    Abstract

    Left ventricular outflow tract (LVOT) calcium is known to be associated with adverse procedural outcomes after transcatheter aortic valve implantation (TAVI), yet its effect on midterm outcomes has not been previously investigated. The aim of this study was to determine the influence of LVOT calcium on 2-year mortality after TAVI. A total of 537 consecutive patients underwent TAVI and 2 groups were established, stratified based on the severity of the LVOT calcium. The primary outcome was 2-year overall survival rate. The ≥moderate LVOT calcium group included 107 patients (19.9%) and the remaining 430 patients (80.1%) were included in the ≤mild LVOT calcium group. After a median follow-up of 717 days (interquartile range 484 to 828), the Kaplan-Meier analysis revealed that the 2-year overall survival probability was significantly lower in the ≥moderate LVOT calcium group than in the ≤mild LVOT calcium group (log-rank p = 0.001). On a Cox hazard model, ≥moderate LVOT calcium was associated with increased all-cause mortality after TAVI (hazard ratio 1.74, p = 0.009). In the subgroup analysis, based on valve designs, SAPIEN 3-TAVI done in the setting of ≥moderate LVOT calcium had a relatively similar survival probability as those of ≤mild LVOT calcium (log-rank p = 0.18), which is in contrast with older generation valves (log-rank p = 0.001). In conclusion, patients with ≥moderate LVOT calcium were shown to have a lower survival probability in the midterm follow-up after TAVI, compared with those with ≤mild LVOT calcium. Patients with high-grade LVOT calcium should be monitored with longer-term follow-ups after TAVI.

    View details for DOI 10.1016/j.amjcard.2017.08.018

    View details for Web of Science ID 000417889000018

    View details for PubMedID 28941599

  • The Fluid Mechanics of Transcatheter Heart Valve Leaflet Thrombosis in the Neosinus CIRCULATION Midha, P. A., Raghav, V., Sharma, R., Condado, J. F., Okafor, I. U., Rami, T., Kumar, G., Thourani, V. H., Jilaihawi, H., Babaliaros, V., Makkar, R. R., Yoganathan, A. P. 2017; 136 (17): 1598-+

    Abstract

    Transcatheter heart valve (THV) thrombosis has been increasingly reported. In these studies, thrombus quantification has been based on a 2-dimensional assessment of a 3-dimensional phenomenon.Postprocedural, 4-dimensional, volume-rendered CT data of patients with CoreValve, Evolut R, and SAPIEN 3 transcatheter aortic valve replacement enrolled in the RESOLVE study (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Dysfunction With Multimodality Imaging and Its Treatment with Anticoagulation) were included in this analysis. Patients on anticoagulation were excluded. SAPIEN 3 and CoreValve/Evolut R patients with and without hypoattenuated leaflet thickening were included to study differences between groups. Patients were classified as having THV thrombosis if there was any evidence of hypoattenuated leaflet thickening. Anatomic and THV deployment geometries were analyzed, and thrombus volumes were computed through manual 3-dimensional reconstruction. We aimed to identify and evaluate risk factors that contribute to THV thrombosis through the combination of retrospective clinical data analysis and in vitro imaging in the space between the native and THV leaflets (neosinus).SAPIEN 3 valves with leaflet thrombosis were on average 10% further expanded (by diameter) than those without (95.5±5.2% versus 85.4±3.9%; P<0.001). However, this relationship was not evident with the CoreValve/Evolut R. In CoreValve/Evolut Rs with thrombosis, the thrombus volume increased linearly with implant depth (R2=0.7, P<0.001). This finding was not seen in the SAPIEN 3. The in vitro analysis showed that a supraannular THV deployment resulted in a nearly 7-fold decrease in stagnation zone size (velocities <0.1 m/s) when compared with an intraannular deployment. In addition, the in vitro model indicated that the size of the stagnation zone increased as cardiac output decreased.Although transcatheter aortic valve replacement thrombosis is a multifactorial process involving foreign materials, patient-specific blood chemistry, and complex flow patterns, our study indicates that deployed THV geometry may have implications on the occurrence of thrombosis. In addition, a supraannular neosinus may reduce thrombosis risk because of reduced flow stasis. Although additional prospective studies are needed to further develop strategies for minimizing thrombus burden, these results may help identify patients at higher thrombosis risk and aid in the development of next-generation devices with reduced thrombosis risk.

    View details for DOI 10.1161/CIRCULATIONAHA.117.029479

    View details for Web of Science ID 000413496200006

    View details for PubMedID 28724752

  • Effect of ascending aortic dimension on acute procedural success following self-expanding transcatheter aortic valve replacement A multicenter retrospective analysis INTERNATIONAL JOURNAL OF CARDIOLOGY Maeno, Y., Yoon, S., Abramowitz, Y., Watanabe, Y., Jilaihawi, H., Lin, M., Chan, J., Sharma, R., Kawashima, H., Israr, S., Kawamori, H., Miyasaka, M., Rami, T., Kazuno, Y., Mangat, G., Kashif, M., Chakravarty, T., Kao, H., Lee, M., Nakamura, M., Kozuma, K., Cheng, W., Makkar, R. R. 2017; 244: 100–105

    Abstract

    Self-expanding (SE) valves are characterized with long stent frame design and the radial force of the device exists both in the inflow and outflow level. Therefore, we hypothesized that device success of SE-valves may be influenced by ascending aortic dimensions (AAD). The aim of this study was to determine the influence of AAD on acute device success rates following SE transcatheter aortic valve replacement (TAVR).In 4 centers in the United States and Asia, 214 consecutive patients underwent SE-TAVR. Outcomes were assessed in line with Valve Academic Research Consortium criteria. AAD was defined as the sum of the short and long axis aortic diameter divided by 2. Overall, device success rate was 85.0%. Multivariate analysis revealed that increased AAD (Odds ratio 1.27) and % oversizing (Odds ratio 0.88) were found to be independent predictors of unsuccessful device implantation. The c-statistic of the model for device success was area under the curve 0.79, sensitivity 81.3% and specificity 44.0%. Co-existence of several risk factors was associated with an exponential fall to 64.2% in device success rate. For a large AAD, however, optimally oversized SE-valves (threshold 16.2%) resulted with high device success rates compared to suboptimal oversizing (88.6% vs. 64.2%, p=0.005).Larger AAD and smaller degrees of oversizing were confirmed to be the most relevant predictors of unsuccessful device implantation following SE-valve implantations. Optimal oversizing of great significance was noted, particularly that with a large AAD.

    View details for DOI 10.1016/j.ijcard.2017.05.120

    View details for Web of Science ID 000406943600018

    View details for PubMedID 28622944

  • Clinical outcomes and prognostic factors of transcatheter aortic valve implantation in bicuspid aortic valve patients ANNALS OF CARDIOTHORACIC SURGERY Yoon, S., Sharma, R., Chakravarty, T., Kawamori, H., Maeno, Y., Miyasaka, M., Nomura, T., Ochiai, T., Israr, S., Rami, T., Nakamura, M., Chen, W., Makkar, R. R. 2017; 6 (5): 463–72

    Abstract

    The purpose of this study was to evaluate the outcomes of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve stenosis (AS).From April 2012 and December 2016, 108 patients with bicuspid AS underwent TAVR using the Sapien XT (34 patients) and Sapien 3 (74 patients) valves. Procedural and clinical outcomes were assessed according to VARC-2 criteria and compared between the two devices.In the overall cohort, the majority of patients were male (71.3%) with an intermediate surgical risk and a mean Society of Thoracic Surgeons (STS) score of 5.2%. Compared to the Sapien XT group, the Sapien 3 group had a significantly lower STS score (3.3%±2.0% vs. 6.7%±3.6%; P=0.001). Compared to the Sapien XT group, the Sapien 3 group had a significantly lower rate of moderate or severe paravalvular leak (2.7% vs. 14.7%; P=0.03) and higher device success (97.3% vs. 82.4%; P=0.006). There were no significant differences between the two groups in terms of 30-day all-cause mortality, stroke, life-threatening bleeding, major vascular complication and acute kidney injury (stage 2 or 3). Cumulative all-cause mortality at 1-year follow-up was 6.9%. There were no significant differences in cumulative event rates for all-cause mortality at 1-year follow-up between the two groups (9.4% vs. 4.6%; log-rank P=0.47). By univariate analysis, major vascular complication was significantly associated with overall all-cause mortality [hazard ratios (HR): 7.57; 95% confidence interval (CI): 1.51-37.86; P=0.014].TAVR using the balloon-expandable valves provided acceptable procedural and clinical outcomes in patients with bicuspid AS. The new-generation Sapien 3 valves showed improved procedural outcomes compared to the early-generation Sapien XT valves.

    View details for DOI 10.21037/acs.2017.09.03

    View details for Web of Science ID 000418471200006

    View details for PubMedID 29062741

    View details for PubMedCentralID PMC5639233

  • Advanced Imaging of Intracranial Atherosclerosis: Lessons from Interventional Cardiology FRONTIERS IN NEUROLOGY Pavlin-Premrl, D., Sharma, R., Campbell, B. V., Mocco, J., Opie, N. L., Oxley, T. J. 2017; 8: 387

    Abstract

    Intracranial atherosclerosis is a major cause of ischemic stroke. Patients with a high degree of stenosis have a significant rate of stroke despite medical therapy. Two randomized trials of stenting have failed to show benefit. Improving periprocedural complication rates and patient selection may improve stenting outcomes. Fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT) are intravascular imaging techniques employed to improve patient selection and stent placement in interventional cardiology. FFR has been shown to improve cardiovascular outcomes when used in patient selection for intervention. Studies of FFR in intracranial atherosclerosis show that the measure may predict which plaques lead to stroke. IVUS is used in cardiology to quantify stenosis and assist with stent placement. Comparisons with histology show that it can reliably characterize plaques. Several case reports of IVUS in intracranial arteries show the technique to be feasible and indicate it may improve stent placement. Plaque characteristics on IVUS may help identify vulnerable plaques. In interventional cardiology, OCT provides excellent visualization of vessel geometry and is useful periprocedurally. Images reliably identify thin-capped fibroatheromas and other plaque features. Case reports indicate that OCT is safe for use in intracranial arteries. OCT can be used to identify perforator vessels and so may be useful in avoiding perforator strokes, a common complication of stenting. Plaque characteristics on OCT may be useful in patient selection.

    View details for DOI 10.3389/fneur.2017.00387

    View details for Web of Science ID 000407590300001

    View details for PubMedID 28855886

    View details for PubMedCentralID PMC5557768

  • Outcomes in Transcatheter Aortic Valve Replacement for Bicuspid Versus Tricuspid Aortic Valve Stenosis JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Yoon, S., Bleiziffer, S., De Backer, O., Delgado, V., Arai, T., Ziegelmueller, J., Barbanti, M., Sharma, R., Perlman, G. Y., Khalique, O. K., Holy, E. W., Saraf, S., Deuschl, F., Fujita, B., Ruile, P., Neumann, F., Pache, G., Takahashi, M., Kaneko, H., Schmidt, T., Ohno, Y., Schofer, N., Kong, W. F., Tay, E., Sugiyama, D., Kawamori, H., Maeno, Y., Abramowitz, Y., Chakravarty, T., Nakamura, M., Kuwata, S., Yong, G., Kao, H., Lee, M., Kim, H., Modine, T., Wong, S., Bedgoni, F., Testa, L., Teiger, E., Butter, C., Ensminger, S. M., Schaefer, U., Dvir, D., Blanke, P., Leipsic, J., Nietlispach, F., Abdel-Wahab, M., Chevalier, B., Tamburino, C., Hildick-Smith, D., Whisenant, B. K., Park, S., Colombo, A., Latib, A., Kodali, S. K., Bax, J. J., Sondergaard, L., Webb, J. G., Lefevre, T., Leon, M. B., Makkar, R. 2017; 69 (21): 2579–89

    Abstract

    Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).This study sought to compare the procedural and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVR multicenter registry.Outcomes of 561 patients with bicuspid AS and 4,546 patients with tricuspid AS were compared after propensity score matching, assembling 546 pairs of patients with similar baseline characteristics. Procedural and clinical outcomes were recorded according to Valve Academic Research Consortium-2 criteria.Compared with patients with tricuspid AS, patients with bicuspid AS had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and a significantly lower device success rate (85.3% vs. 91.4%; p = 0.002). Early-generation devices were implanted in 320 patients with bicuspid and 321 patients with tricuspid AS, whereas new-generation devices were implanted in 226 and 225 patients with bicuspid and tricuspid AS, respectively. Within the group receiving early-generation devices, bicuspid AS had more frequent aortic root injury (4.5% vs. 0.0%; p = 0.015) when receiving the balloon-expanding device, and moderate-to-severe paravalvular leak (19.4% vs. 10.5%; p = 0.02) when receiving the self-expanding device. Among patients with new-generation devices, however, procedural results were comparable across different prostheses. The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid AS (17.2% vs. 19.4%; p = 0.28).Compared with tricuspid AS, TAVR in bicuspid AS was associated with a similar prognosis, but lower device success rate. Procedural differences were observed in patients treated with the early-generation devices, whereas no differences were observed with the new-generation devices.

    View details for DOI 10.1016/j.jacc.2017.03.017

    View details for Web of Science ID 000401695900001

    View details for PubMedID 28330793

  • Optimal sizing for SAPIEN 3 transcatheter aortic valve replacement in patients with or without left ventricular outflow tract calcification EUROINTERVENTION Maeno, Y., Abramowitz, Y., Jilaihawi, H., Israr, S., Yoon, S., Sharma, R. P., Kazuno, Y., Kawamori, H., Miyasaka, M., Rami, T., Mangat, G., Takahashi, N., Okuyama, K., Kashif, M., Chakravarty, T., Nakamura, M., Cheng, W., Makkar, R. R. 2017; 12 (18): E2177–E2185

    Abstract

    The impact of left ventricular outflow tract calcification (LVOT-CA) on SAPIEN 3 transcatheter aortic valve replacement (S3-TAVR) is not well understood. The aims of the present study were to determine optimal device sizing for S3-TAVR in patients with or without LVOT-CA and to evaluate the influence of residual paravalvular leak (PVL) on survival after S3-TAVR in these patients.This study analysed 280 patients (LVOT-CA=144, no LVOT-CA=136) undergoing S3-TAVR. Optimal annular area sizing was defined as % annular area sizing related to lower rates of ≥mild PVL. Annular area sizing was determined as follows: (prosthesis area/CT annulus area-1)×100. Overall, ≥mild PVL was present in 25.7%. Receiver operating characteristic curve analysis for prediction of ≥mild PVL in patients with LVOT-CA showed that 7.2% annular area sizing was identified as the optimal threshold (area under the curve [AUC] 0.71). Conversely, annular area sizing for no LVOT-CA appeared unrelated to PVL (AUC 0.58). Aortic annular injury was seen in four patients (average 15.5% annular area oversizing), three of whom had LVOT-CA. Although there was no difference in one-year survival between patients with ≥mild PVL and without PVL (log-rank p=0.91), subgroup analysis demonstrated that patients with ≥moderate LVOT-CA who had ≥mild PVL had lower survival compared to patients with ≥mild PVL and none or mild LVOT-CA (log-rank p=0.010).In the setting of LVOT-CA, an optimally sized S3 valve is required to reduce PVL and to increase survival following TAVR.

    View details for Web of Science ID 000400782100005

    View details for PubMedID 28117281

  • Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings. Journal of the American College of Cardiology Yoon, S. H., Whisenant, B. K., Bleiziffer, S. n., Delgado, V. n., Schofer, N. n., Eschenbach, L. n., Fujita, B. n., Sharma, R. n., Ancona, M. n., Yzeiraj, E. n., Cannata, S. n., Barker, C. n., Davies, J. E., Frangieh, A. H., Deuschl, F. n., Podlesnikar, T. n., Asami, M. n., Dhoble, A. n., Chyou, A. n., Masson, J. B., Wijeysundera, H. C., Blackman, D. J., Rampat, R. n., Taramasso, M. n., Gutierrez-Ibanes, E. n., Chakravarty, T. n., Attizzani, G. F., Kaneko, T. n., Wong, S. C., Sievert, H. n., Nietlispach, F. n., Hildick-Smith, D. n., Nombela-Franco, L. n., Conradi, L. n., Hengstenberg, C. n., Reardon, M. J., Kasel, A. M., Redwood, S. n., Colombo, A. n., Kar, S. n., Maisano, F. n., Windecker, S. n., Pilgrim, T. n., Ensminger, S. M., Prendergast, B. D., Schofer, J. n., Schaefer, U. n., Bax, J. J., Latib, A. n., Makkar, R. R. 2017; 70 (9): 1121–31

    Abstract

    Limited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair.This study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]).From the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria.A total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176 patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; p < 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; p = 0.001) due to more frequent second valve implantation (11.1% vs. 2.8%; p = 0.008), and lower device success (76.4% vs. 89.2%; p = 0.009) due to more frequent reintervention (16.7% vs. 7.4%; p = 0.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3 mm Hg vs. 5.8 ± 2.7 mm Hg; p = 0.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; p = 0.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; p = 0.03), acute kidney injury (11.1% vs. 4.0%; p = 0.03), and subsequent lower procedural success (58.3% vs. 79.5%; p = 0.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, p = 0.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; p = 0.005).The TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

    View details for PubMedID 28838360

  • Controversies in Out of Hospital Cardiac Arrest? Interventional cardiology clinics Sharma, R. P., Stub, D. 2016; 5 (4): 551-559

    Abstract

    Cardiac arrest is a major cause of morbidity and mortality and accounts for nearly 500,000 deaths annually in the United States. In patients suffering out-of-hospital cardiac arrest, survival is less than 15%, with considerable regional variation. Although most deaths occur during the initial resuscitation, an increasing proportion occur in patients hospitalized after initially successful resuscitation. In these patients, the significant subsequent morbidity and mortality is due to "post cardiac arrest syndrome." Until recently, most single interventions have yielded little improvement in rates of survival; however, there is growing recognition that optimal treatment strategies during the postresuscitation phase may improve outcomes.

    View details for DOI 10.1016/j.iccl.2016.06.011

    View details for PubMedID 28582003

  • Impact of Body Mass Index on the Outcomes Following Transcatheter Aortic Valve Implantation CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Abramowitz, Y., Chakravarty, T., Jilaihawi, H., Cox, J., Sharma, R. P., Mangat, G., Nakamura, M., Cheng, W., Makkar, R. R. 2016; 88 (1): 127–34

    Abstract

    To investigate the influence of body mass index (BMI) on short- and midterm outcomes following transcatheter aortic valve implantation (TAVI).Although obesity is a major risk factor for cardiovascular mortality, numerous studies reported a beneficial effect of obesity on survival in patients with cardiovascular disease and in patients after cardiac interventions. Moreover, all previous reports examining the relation between BMI and outcomes following TAVI have underscored the "obesity paradox" in these patients.During a 3 year period, 805 patients with severe aortic stenosis that underwent TAVI at our institute were evaluated. Based on baseline BMI, patients were classified as normal weight (18.5-24.9 kg/m(2) ), overweight (25.0-29.9 kg/m(2) ), or obese (≥30 kg/m(2) ). TAVI endpoints, device success, and adverse events were considered according to the Valve Academic Research Consortium (VARC)-2 definitions.Obese patients were significantly younger, had higher prevalence of diabetes mellitus and chronic lung disease, and had lower prevalence of frailty. Device success was similar between the 3 groups. All-cause mortality up to 30 days was 2.9% (10/340) vs 4.5% (12/268) vs 0.5% (1/186) in patients with normal weight, overweight, and obesity, respectively (p = 0.048). In a multivariable model, overweight and obese patients had similar overall mortality compared to patients with normal weight.We found no evidence for the existence of an obesity paradox following TAVI. Correction for possible confounders such as frailty in the present cohort may explain the discrepancy between the current report and the previous reports that suggested a protective effect for increased BMI following TAVI. © 2016 Wiley Periodicals, Inc.

    View details for DOI 10.1002/ccd.26394

    View details for Web of Science ID 000379984000028

    View details for PubMedID 26756702

  • Outcomes in Patients With Transcatheter Aortic Valve Replacement and Left Main Stenting The TAVR- LM Registry JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Chakravarty, T., Sharma, R., Abramowitz, Y., Kapadia, S., Latib, A., Jilaihawi, H., Poddar, K., Giustino, G., Ribeiro, H. B., Tchetche, D., Monteil, B., Testa, L., Tarantini, G., Facchin, M., Lefevre, T., Lindman, B. R., Hariri, B., Patel, J., Takahashi, N., Matar, G., Mirocha, J., Cheng, W., Tuzcu, M. E., Sievert, H., Rodes-Cabau, J., Colombo, A., Finkelstein, A., Fajadet, J., Makkar, R. R. 2016; 67 (8): 951–60

    Abstract

    A percutaneous approach with transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) of the left main coronary artery (LM) is frequently used in high-risk patients with coexisting aortic stenosis and LM disease. Outcomes of TAVR plus LM PCI have not been previously reported.The primary objective of the TAVR-LM registry is to evaluate clinical outcomes in patients undergoing TAVR plus LM PCI.Clinical, echocardiographic, computed tomographic, and angiographic characteristics were retrospectively collected in 204 patients undergoing TAVR plus LM PCI. In total, 128 matched patient pairs were generated by performing 1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,188 control patients undergoing TAVR without LM revascularization.One-year mortality (9.4% vs. 10.2%, p = 0.83) was similar between the TAVR plus LM PCI cohort and matched controls. One-year mortality after TAVR plus LM PCI was not different in patients with unprotected compared with protected LMs (7.8% vs. 8.1%, p = 0.88), those undergoing LM PCI within 3 months compared with those with LM PCI greater than 3 months before TAVR (7.4% vs. 8.6%, p = 0.61), and those with ostial versus nonostial LM stents (10.3% vs. 15.6%, p = 0.20). Unplanned LM PCI performed because of TAVR-related coronary complication, compared with planned LM PCI performed for pre-existing LM disease, resulted in increased 30-day (15.8% vs. 3.4%, p = 0.013) and 1-year (21.1% vs. 8.0%, p = 0.071) mortality.Despite the anatomic proximity of the aortic annulus to the LM, TAVR plus LM PCI is safe and technically feasible, with short- and intermediate-term clinical outcomes comparable with those in patients undergoing TAVR alone. These results suggest that TAVR plus LM PCI is a reasonable option for patients who are at high risk for surgery.

    View details for DOI 10.1016/j.jacc.2015.10.103

    View details for Web of Science ID 000370490000009

    View details for PubMedID 26916485

    View details for PubMedCentralID PMC5091082

  • Impact of Preprocedural B-Type Natriuretic Peptide Levels on the Outcomes After Transcatheter Aortic Valve Implantation AMERICAN JOURNAL OF CARDIOLOGY Abramowitz, Y., Chakravarty, T., Jilaihawi, H., Lee, C., Cox, J., Sharma, R. P., Mangat, G., Cheng, W., Makkar, R. R. 2015; 116 (12): 1904–9

    Abstract

    There are limited data on the effect of baseline B-type natriuretic peptide (BNP) on the outcome after transcatheter aortic valve implantation (TAVI). We investigated the influence of baseline BNP levels on the short-term and midterm clinical outcomes after TAVI. During a 3-year period, 780 patients with severe aortic stenosis underwent TAVI at our institute and had baseline BNP levels. We compared the high, mid, and low tertiles of BNP levels. TAVI end points, device success, and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. Device success was significantly lower for patients with high BNP (98.1% vs 96.2% vs 91.9% for the low, mid, and high BNP tertiles, respectively; p = 0.003). All-cause mortality up to 30 days was 1.2% (3 of 260) versus 2.3% (6 of 260) versus 5% (13 of 260), respectively (p = 0.03). Six-month mortality rate was 4.1% (10 of 241) for the low BNP tertile, 5% (12 of 239) for the mid BNP tertile, and 17.1% (40 of 234) for the high BNP tertile (p <0.001). In the multivariate model, high tertile of baseline BNP was found to be significantly associated with all-cause mortality (hazard ratio 3.3, 95% confidence interval 1.64 to 6.48; p = 0.001). In conclusion, elevated BNP levels are associated with increased short-term and midterm mortality after TAVI. We recommend measurement of baseline BNP as part of risk stratification models for TAVI.

    View details for DOI 10.1016/j.amjcard.2015.09.031

    View details for Web of Science ID 000366786500019

    View details for PubMedID 26602075

  • Unmasking of familial long QT syndrome type 2 with crystal methamphetamine exposure HEART RHYTHM Kumar, S., Sharma, R., Kalman, J. M. 2014; 11 (10): 1836–38

    View details for DOI 10.1016/j.hrthm.2014.05.034

    View details for Web of Science ID 000343112200031

    View details for PubMedID 24882508

  • Randomized double-blind placebo-controlled crossover study to determine the effects of esomeprazole on inhibition of platelet function by clopidogrel JOURNAL OF THROMBOSIS AND HAEMOSTASIS Fernando, H., Bassler, N., Habersberger, J., Sheffield, L. J., Sharma, R., Dart, A. M., Peter, K. H., Shaw, J. A. 2011; 9 (8): 1582–89

    Abstract

    Pharmacokinetic studies suggest that clopidogrel and esomeprazole are metabolized by similar hepatic enzymes; however, previous studies have not identified a biochemical interaction.To determine whether addition of esomeprazole to patients receiving aspirin and clopidogrel reduces the antiplatelet effects of clopidogrel.Patients with a history of an acute coronary syndrome who had previously received clopidogrel were recruited. Subjects were commenced on clopidogrel and randomized to one of two treatment arms (esomeprazole or placebo) for 6 weeks. Following a 2-week washout period for study medications, patients were crossed over onto the alternative treatment arm for a further 6 weeks. Platelet function tests were undertaken at baseline, following the first treatment period, after washout and following the second treatment period.Thirty-one patients were enrolled. Significant attenuation of clopidogrel's antiplatelet effects was seen with co-administration of esomeprazole compared with placebo. Vasodilator stimulated phosphoprotein (VASP), platelet aggregometry (area under the curve (AUC)) and VerifyNow results were 54.7% ± 2.8 platelet reactivity index (PRI), 66.3 ± 2.6 AUC units and 213.1 ± 14.1 platelet reactivity units (PRU) with esomeprazole vs. 47% ± 2.7 PRI, 59.7 ± 3.7 AUC units and 181.4 ± 14.6 PRU with placebo (P < 0.01 esomeprazole vs. placebo for all measures). There was no significant difference in platelet aggregometry (maximal aggregation) between the esomeprazole group (68.9% ± 2.7 units) and placebo-treated group (64.5% ± 4.1 units; P > 0.05).Esomeprazole when co-administered with aspirin and clopidogrel results in a significant attenuation of clopidogrel's antiplatelet effects.

    View details for DOI 10.1111/j.1538-7836.2011.04414.x

    View details for Web of Science ID 000293791400019

    View details for PubMedID 21696537